RTM Didn't Cause This Problem. It Might Still Pay For It.

Less than a decade ago, when I owned my practice, the thing that killed adherence was always distance. It was rarely ever willpower. A patient leaves your clinic with a home exercise program and three good intentions, and by day four, life happens. The kids need a ride somewhere. Work runs late. The exercises sit on a printed sheet on the kitchen counter, and nobody’s watching to notice they never got done.

That gap between visits, is where most of recovery quietly succeeds or quietly fails. It’s also the gap Remote Therapeutic Monitoring was built to close. Not a billing code bolted onto therapy. An actual answer to the actual problem: care doesn’t stop being care just because the patient walked out the door.

CMS’s proposed 2027 Physician Fee Schedule, released two weeks ago, could end RTM as a viable model. Not reform it. End it.

I want to walk through what’s actually being proposed, where I think CMS has a real point, where I think they’ve gotten it wrong, and who ends up paying for that mistake if it isn’t fixed before the rule finalizes.

Strip away the regulatory language and there are three changes that matter:

RTM would only be billable for patients with an existing relationship to the practice. Fine. Good, even. Nobody serious about this industry is out here cold-calling Medicare patients into a monitoring program they didn’t ask for.

A separate, billable visit would be required to formally start RTM. Also fine. It’s a documentation step, not a threat to the model.

And then the one that actually matters: RTM could only be furnished by staff directly employed by the billing practice. Not contracted. Not leased. Not supported by an outside clinical team. Employed, full stop.

The published rates in Addendum B, the actual numbers CMS put forward, are a real cut, and they deserve pushback in their own right. Nobody should wave that off, and I’d encourage anyone reading this to say so in their comments. Those cuts are one half of the squeeze, and on their own they’d make RTM hard to sustain at scale. The other half is quieter, and to me more dangerous, because it doesn’t just thin the margin. It removes the very delivery model that makes RTM reachable in the first place. The rates decide whether RTM pays. The staffing mandate decides whether most practices can offer it at all. Put the two together, and you don’t reform RTM, you end it for everyone who can’t absorb a rate cut and staff the work in-house at the same time.

I’m not going to pretend this rule came out of nowhere, because it didn’t. But I want to be precise about what it came out of, because the precision matters for everything that follows.

The HHS Office of Inspector General has spent two years documenting real problems in remote monitoring billing. Specifically Remote Physiologic Monitoring, RPM, blood pressure cuffs, glucose monitors, chronic condition tracking. Spending on RPM grew tenfold in three years. Nearly half of RPM enrollees never actually got the full service, meaning someone was collecting a check for data nobody looked at. Some companies built entire businesses around cold-calling Medicare beneficiaries and signing them up for RPM with no clinical relationship at all. That’s not a gray area. That’s the exact behavior good regulation exists to stop.

If your business model depends on billing Medicare for services patients didn’t ask for and clinicians never reviewed, you should be worried right now. That model deserves to disappear. CMS is right to go after it.

The part worth saying plainly, because it’s the whole ballgame, is those findings are about RPM. Not RTM. The OIG reports say so themselves, in their own language. They did not review RTM claims data. There is no known evidence of the same fraud, waste, and abuse patterns occurring in RTM.

CMS is applying the RPM fix to RTM anyway, on the assumption that a related code family must have a related problem. I understand why the mix-up is easy to make on paper. Both sit under the umbrella of remote monitoring, both showed up in the fee schedule around the same time, and RPM and RTM are close enough as acronyms that it’s an easy pair to blur together if you’re not living in this world every day. But they are not the same program, serving the same patients, with the same risk profile. RPM tracks a chronic condition indefinitely, with no natural end point, which is exactly the structure that let bad actors turn it into a subscription business. RTM is bounded by an active episode of therapy, ordered by a provider who’s already treating the patient, tied to a plan of care with a beginning and an end. Lumping them together because they share a category on a spreadsheet isn’t evidence-based rulemaking. It’s precaution dressed up as findings, and it’s the difference between fixing a demonstrated problem and pre-emptively punishing a category of care because it sits on the same page of the fee schedule as one.

This isn’t a hypothetical about what good RTM does. We have the data because we’ve been running it at real scale for years.

In a peer-reviewed case-control study of 1,224 patients across 95 clinics at a national physical therapy network, published in Archives of Rehabilitation Research and Clinical Translation (2025), the difference was clear on both counts. Patients enrolled in RTM show up to their in-person visits more reliably than patients who aren’t: 36% attended more than two visits a week, compared to 24% of the PT-only group, likely because someone checking in between appointments keeps the plan of care top of mind instead of letting it slide.

And patients on RTM reach better functional outcomes, not marginally: 72% hit their discharge functional benchmark versus 63% of the comparison group, and RTM participation independently predicted hitting that benchmark even after controlling for the other variables, but in a way that shows up clearly against a non-RTM comparison group. That’s the whole case in two data points: better attendance, better outcomes. Not a billing code. A patient who does the work and gets better because someone was paying attention on the days they weren’t in the clinic.

Here’s what the employed-staff mandate actually asks of a practice, and it’s worth sitting with the absurdity of it.

Physical Therapy is in the middle of a workforce shortage that’s been building for years. Clinics have had job postings open for months, some for years, with no qualified applicants. The therapists on staff right now are already stretched across full patient loads, documentation, and increasingly the kind of administrative burden that’s driving people out of the profession entirely. Most clinics are operating at or above their in-person capacity already. There is no bench of idle clinical staff sitting around waiting to pick up remote monitoring work.

RTM exists precisely because that capacity doesn’t exist inside the four walls of the clinic. It’s the mechanism that lets a practice extend its reach to patients between visits without requiring it to hire its way out of a labor market that has no supply to hire from. Take away the ability to use outside clinical support, staffing optionality, and you haven’t made RTM safer. You’ve made it impossible for the practices that need it most to offer it at all.

And the practices that need it most are disproportionately rural and underserved. A five-provider clinic in a community where the nearest specialist is ninety minutes away doesn’t have a bench of extra PTs to reassign to remote monitoring. It has the staff it has, doing everything it’s already asking of them. If the only lawful way to deliver RTM is with employed staff that clinic doesn’t have and can’t hire, then RTM isn’t available to that clinic’s patients. Not because CMS said patients in rural Ohio don’t deserve better outcomes. But that’s the practical effect of a rule that ties access to a staffing model those communities structurally cannot meet.

That’s the contradiction sitting at the center of this proposal. CMS isn’t arguing that RTM fails to improve outcomes. The clinical case isn’t in dispute. What CMS is doing is telling practices they can only deliver that improved outcome using a workforce that doesn’t exist in the numbers required, in the places that need it most. Functionally, that’s the same as telling those patients they’re not eligible for better outcomes. It just arrives wrapped in a staffing requirement instead of a coverage denial.

The comment period closes September 14. The final rule is expected around the end of October. Between now and then, there’s a real, workable path to a better outcome, and it doesn’t require CMS to abandon the instinct behind this rule, only to aim it correctly.

The fix is not going to be “who’s on whose payroll.” It’s going to be evidence of real clinical oversight: a documented plan of care, a treating provider who ordered the service and reviews the outcomes, transparency into who’s actually performing the monitoring regardless of their employer. That answers the actual, documented RPM problem, opaque delivery, no clinical relationship, nobody accountable for the data, without requiring every practice in the country to solve a labor shortage that has nothing to do with why OIG raised the alarm in the first place. And on the rates, the ask is just as straightforward: value RTM against the outcomes it actually produces, not against a monitoring category it was wrongly grouped with.

I’m optimistic that this is fixable, if the industry shows up during the comment period with the actual distinction CMS is missing, instead of after the final rule lands. Clinicians and practice owners, especially the ones in rural and underserved communities who stand to lose the most, should be the loudest voices in this process. Not because a vendor asked them to. Because they’re the ones who know exactly what it means to be down two open positions for a year and still be expected to reach every patient who needs care.

I don’t think RTM deserves to survive because it’s convenient for anyone’s business model. I think it deserves to survive because a patient doing their exercises alone at 7pm, three days after their last visit, in a town where the clinic is already stretched thin, is better off with someone paying attention than without one. That’s the argument worth making. Take away staffing optionality, and you haven’t protected that patient from anything. You’ve just made sure nobody’s watching.

For any practice owner or clinician who’s felt what it’s like to have openings sit unfilled for months while patient need doesn’t slow down, the comment period is open.

CMS is legally required to read and respond to what gets submitted. Worth using it.

Ben Barron | SVP @ Net Health / Limber | LinkedIn